Oncology Emergencies – GCC Nursing Clinical Guide

⚠ TIME-CRITICAL: ANTIBIOTICS WITHIN 1 HOUR OF PRESENTATION Each hour of delay in antibiotic administration in neutropenic sepsis significantly increases mortality. This is a monitored KPI in GCC oncology centres.

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Definition

Neutropenic Sepsis Criteria

Diagnostic Criteria Temperature >38°C or <36°C AND neutrophil count <0.5 × 10⁹/L (or expected to fall to this level within 48h in a patient receiving myelosuppressive chemotherapy)

Absolute Neutrophil Count (ANC) Classification

ANC	Severity	Infection Risk
<0.5 × 10⁹/L	Severe	Very High
0.5–1.0 × 10⁹/L	Moderate	High
1.0–1.5 × 10⁹/L	Mild	Moderate

Typical Onset Post-Chemotherapy

Nadir (lowest neutrophil point) typically occurs 7–14 days post-chemotherapy. Patient education about fever monitoring is critical during this window.

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MASCC Risk Score

Multinational Association for Supportive Care in Cancer

Factor	Score
Burden of illness: no/mild symptoms	5
Burden of illness: moderate symptoms	3
No hypotension (SBP ≥90 mmHg)	5
No COPD	4
Solid tumour or no fungal infection	4
No dehydration	3
Outpatient status at onset	3
Age <60 years	2

Score ≤21 = HIGH RISK → Inpatient IV antibiotics mandatory Score >21 = Low risk (may consider oral outpatient therapy in selected cases)

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Oncology-Adapted Sepsis 6 (UK Sepsis Trust)

Complete ALL within 1 hour of recognition

1
Oxygen: High-flow O₂ if SpO₂ <94%. Target 94–98% (88–92% in COPD).
2
Blood cultures ×2: Peripheral vein AND central line (if present). Do NOT delay antibiotics beyond 30 minutes waiting for cultures.
3
IV antibiotics WITHIN 1 HOUR: First-line: Piperacillin-tazobactam (Tazocin) 4.5g TDS IV. If penicillin allergy or resistant organisms suspected: Meropenem 1g TDS IV.
4
IV fluid bolus: 500mL crystalloid (0.9% NaCl) over 15 minutes if MAP <65 mmHg or signs of shock. Reassess after each bolus.
5
Lactate: Arterial or venous sample. Lactate >2 mmol/L indicates tissue hypoperfusion; >4 mmol/L = septic shock.
6
Urine output monitoring: Insert urinary catheter if not already present. Target >0.5 mL/kg/hr. Monitor hourly.

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G-CSF (Filgrastim)

Granulocyte Colony-Stimulating Factor

Primary Prophylaxis

Given with first cycle of high-risk chemotherapy regimens (>20% febrile neutropenia risk, e.g. CHOP, FEC-D). Reduces duration and severity of neutropenia.

Secondary Prophylaxis

After a previous episode of febrile neutropenia on the same regimen. Allows chemotherapy to continue at planned dose intensity.

Role in Established Neutropenia

Shortens duration of neutropenia by 1–2 days. Start 24–72h after chemotherapy. Do NOT start during active febrile neutropenia episode without oncology review as may mobilise infected marrow cells.

Standard Dosing

          Filgrastim 5 mcg/kg SC daily until ANC >2 × 10⁹/L post-nadir (usually 5–7 days)

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Fungal Infection Risk

Aspergillus & Candida

High-Risk Patients

Prolonged neutropenia >7 days (haematology patients: AML, ALL)
Allogeneic stem cell transplant recipients
High-dose steroids
Previous invasive fungal infection

Prophylaxis Regimens

Drug	Target	Indication
Fluconazole	Candida	Standard haematology
Posaconazole	Aspergillus + Candida	AML/MDS induction, SCT
Voriconazole	Aspergillus	Post-SCT, high risk

72-Hour Rule Febrile neutropenia not responding to broad-spectrum antibiotics at 72 hours → ADD empirical antifungal (e.g. caspofungin or liposomal amphotericin B). Consider CT chest for aspergillus (halo sign).

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Typhlitis (Neutropenic Enterocolitis)

GI emergency in neutropenic patients

Presentation

Right iliac fossa (RIF) / right lower quadrant pain
Fever (already neutropenic)
Nausea, vomiting, diarrhoea
Bowel wall oedema/thickening on imaging

Diagnosis

CT abdomen: bowel wall thickening >4mm (caecum/right colon). Ultrasound as adjunct. Avoid colonoscopy (perforation risk in neutropenia).

Management

1
Bowel rest: Nil by mouth, NG tube if vomiting
2
IV antibiotics: Broad-spectrum covering gram-negatives and anaerobes (add metronidazole to standard neutropenic cover)
3
IV fluids & nutrition: TPN may be required
4
Surgical review: For perforation, uncontrolled bleeding, or failure to improve

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Reverse Barrier / Protective Isolation Nursing

Environment

          Single room with positive pressure/HEPA filtration preferred. Strict hand hygiene before entry. Laminar airflow rooms for SCT patients.

Visitors

          Restrict to essential visitors only. No visitors with active infections, recent live vaccines, or children with infectious illnesses.

Diet

          Low-microbial diet (avoid raw salads, soft cheeses, raw eggs, rare meat, tap water in some settings). No fresh flowers/plants.

⚠ Adjusted Calcium >3.4 mmol/L = ONCOLOGICAL EMERGENCY Severe hypercalcaemia causes life-threatening cardiac arrhythmias, renal failure, and coma. Immediate IV rehydration mandatory.

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Definition & Correction Formula

Albumin-Adjusted Calcium Formula Adjusted Ca²⁺ = Measured Ca²⁺ + 0.02 × (40 – measured albumin in g/L)

Severity Classification

Level	Adjusted Ca²⁺	Urgency
Normal	2.1–2.6 mmol/L	—
Mild	2.6–3.0 mmol/L	Monitor
Moderate	3.0–3.4 mmol/L	Treat within 24h
Severe	>3.4 mmol/L	EMERGENCY

Prevalence

Hypercalcaemia of malignancy affects 10–30% of cancer patients, most commonly in advanced/metastatic disease. It carries a poor prognosis (median survival weeks to months without treatment of underlying cancer).

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Causes & Pathophysiology

PTHrP-Mediated (Most Common ~80%)

Squamous cell carcinomas (lung, head & neck, oesophagus)
Breast cancer
Renal cell carcinoma
Parathyroid hormone-related protein → ↑ osteoclast activity + ↑ renal Ca²⁺ reabsorption

Osteolytic Bone Metastases

Breast cancer (mixed lytic/blastic)
Multiple myeloma (osteoclast-activating factors)
Direct bone destruction → Ca²⁺ release

Other Mechanisms

1,25-dihydroxyvitamin D production (lymphoma)
Ectopic PTH production (very rare)

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Clinical Features: "Bones, Stones, Groans, Thrones, Moans"

Bones

          Bone pain, pathological fractures, periarticular calcification, metastatic calcification

Stones

          Renal stones (nephrolithiasis), nephrocalcinosis, polyuria (nephrogenic DI), polydipsia, dehydration

Groans

          Abdominal pain, nausea, vomiting, constipation, anorexia, acute pancreatitis (rare)

Thrones

          Polyuria, polydipsia (osmotic diuresis from calciuria), dehydration → pre-renal AKI

Moans

          Confusion, lethargy, depression, psychosis, muscle weakness, hyporeflexia, coma (severe)

Cardiac

          Short QT interval on ECG, bradycardia, heart block, cardiac arrest (Ca²⁺ >3.7 mmol/L)

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Management Algorithm

1
IV Hydration (FIRST LINE): 0.9% sodium chloride 4L over 24 hours. Promotes calciuresis by increasing GFR and inhibiting proximal tubular calcium reabsorption. Reassess fluid balance every 4–6 hours.
2
IV Bisphosphonate (Definitive treatment):
• Zoledronic acid 4mg IV over 15 minutes (preferred – single dose, long-acting)
• Pamidronate 60–90mg IV over 2–4 hours (alternative)
• Check eGFR before: withhold if eGFR <30 mL/min or adjust dose. Onset 48–72h, duration 3–4 weeks.
3
Calcitonin (Salmon calcitonin 4–8 IU/kg SC/IM Q6-12h): Rapid onset (hours) but tachyphylaxis within 24–48h limits prolonged use. Bridge therapy until bisphosphonate takes effect.
4
Denosumab (120mg SC): RANK-L inhibitor. Used for bisphosphonate-refractory hypercalcaemia or when bisphosphonate contraindicated (severe renal impairment). Onset 4–10 days.
5
Treat underlying malignancy: Long-term control requires treatment of the cancer (chemotherapy, hormone therapy, immunotherapy).

Monitoring Protocol Hourly urine output (target >100mL/hr during rehydration) · Serum calcium daily · U&E, creatinine, phosphate 12-hourly · ECG monitoring if Ca²⁺ >3.0 · Fluid balance strict 4-hourly · Weight daily

⚠ SVCO Grade 4 (Stridor/Altered Consciousness) = Immediate Life Threat Secure airway, apply oxygen, start dexamethasone immediately, and call for urgent senior/anaesthetics review.

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Definition & Pathophysiology

Obstruction or compression of the superior vena cava causing impaired venous drainage from the head, neck, upper limbs, and upper thorax. Results in venous hypertension above the obstruction.

Key Causes

Cause	% of Cases	Notes
Lung cancer (NSCLC/SCLC)	~50%	Right-sided tumours
Lymphoma	~15%	Mediastinal
Central line/pacemaker thrombosis	~15%	Increasing incidence
Mediastinal metastases	~10%	Breast, germ cell
Benign (fibrosing mediastinitis)	~5%	Rare

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Clinical Features & Grading

Symptoms (remember: FACE)

Facial and arm oedema (especially morning), suffusion/plethora of face
Arms — venous distension, arm swelling, prominent chest wall veins (collaterals)
Cerebral — headache (worse bending forward/lying flat), visual changes, confusion
Effort dyspnoea, stridor (laryngeal/tracheal oedema = severe)

Pemberton's Sign

Raising arms above head → facial congestion, cyanosis, respiratory distress (positive = significant SVCO)

SVCO Grading (CTCAE-based)

Grade	Description	Management
0	Radiological finding, asymptomatic	Monitor
1	Oedema, no functional impairment	Outpatient
2	Functional impairment (dyspnoea)	Urgent
3	Severe dyspnoea, facial oedema	Emergency
4	Stridor, confusion, haemodynamic compromise	IMMEDIATE

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Emergency Management

Immediate Actions

1
Positioning: Sit patient upright at 30–45°. Do NOT lay flat.
2
Oxygen: High-flow O₂ via non-rebreathe mask if hypoxic.
3
Dexamethasone 8mg IV: Reduces tumour-associated oedema and peritumour inflammation. Onset 6–24 hours.
4
IV access: Lower limbs ONLY (avoid upper limb and neck veins — worsens venous congestion).
5
Urgent CT chest with contrast: Defines level/extent of obstruction and guides intervention.

Definitive Treatment Options

Endovascular Stenting (Fastest — Hours) Best for rapid symptom relief. Percutaneous SVC stenting provides relief within hours. Preferred for Grade 3–4. Anticoagulation may be required post-stenting.

Radiotherapy Excellent response in lymphoma (2–3 weeks). Also used for NSCLC. Slower onset than stenting (days to weeks). Requires histological diagnosis first.

Chemotherapy First-line in SCLC, lymphoma (highly chemosensitive). Response in 1–2 weeks. Combined chemo-RT for SCLC.

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Nursing Management & Monitoring

Positioning

          Head of bed 30–45° at all times. Avoid Trendelenburg position. Elevate head on 2–3 pillows. Support oedematous arms on pillows.

IV Access Rule

          ABSOLUTELY NO IV lines, blood pressure cuffs, or venepuncture in upper limbs or neck. Use lower limbs or femoral access only. Document this clearly in patient notes.

Monitoring Priorities

          Respiratory rate every 30 min (Grade 3–4) · Stridor assessment · SpO₂ continuous · Neurological observations · Pemberton's sign reassessment

Anticoagulation

          If thrombosis is the primary cause or component: LMWH (enoxaparin) weight-based dosing. Check platelets before starting. Consider IVC filter if anticoagulation contraindicated.

Patient Education

          Report worsening breathing, new stridor, visual changes, confusion immediately. Sleep with head elevated. Avoid tight-fitting clothing around neck/arms.

Documentation

          Record facial oedema severity (1–4 scale), arm circumference measurement, respiratory observations, and response to dexamethasone every 4 hours.

⚠ METASTATIC SPINAL CORD COMPRESSION: ONCOLOGICAL EMERGENCY Delay in diagnosis and treatment leads to permanent paralysis. Ambulatory status at time of treatment is the single strongest predictor of post-treatment function. Every hour matters.

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Metastatic Spinal Cord Compression (MSCC)

NICE Guideline CG75

Most Common Primary Cancers

Cancer	Frequency	Spinal Level
Breast	Most common overall	Thoracic
Prostate	Common (bone-avid)	Lumbar/thoracic
Lung	Common (rapid onset)	Any
Myeloma	Common	Thoracic/lumbar
Renal cell	Moderate	Any

Mechanism

Haematogenous spread to vertebral body → tumour extends into epidural space → direct compression of spinal cord/cauda equina + vascular compromise.

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Clinical Presentation

Recognise early — symptoms are progressive

Back Pain is the Cardinal Early Sign (Present in ~95%) Central back pain, often worse at night/lying flat (unlike mechanical pain), may be band-like/girdle distribution. Worse with Valsalva manoeuvre.

Progressive Symptom Sequence

1
Back pain (weeks/months before neurological deficit)
2
Limb weakness — often bilateral (upper or lower depending on level)
3
Sensory changes — numbness, tingling; sensory level on examination
4
Bladder/bowel dysfunction — urinary retention, constipation, faecal incontinence. LATE SIGN — often irreversible if delayed treatment
5
Paralysis — complete motor/sensory loss below lesion level

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Emergency Management (NICE CG75)

1
Dexamethasone loading dose 16mg IV immediately. Then 8–16mg/day in divided doses (with PPI cover — omeprazole). Reduces oedema around cord.
2
MRI whole spine within 24 hours (NICE standard). Within 4 hours if acute neurological deficit or suspected cauda equina. Do NOT wait for CT only.
3
Spinal precautions until MRI confirms stability: do NOT mobilise, maintain spinal alignment, log-rolling for all repositioning (minimum 3-person technique).
4
Urinary catheter if retention/incontinence present. Bladder scan if unsure.
5
Urgent oncology/spinal surgery referral for treatment planning.

Definitive Treatment Options

Radiotherapy (Most Common) Palliative RT: 8Gy single fraction or 20Gy in 5 fractions. Best for radiosensitive tumours (haematological, breast, prostate). Start within 24h of diagnosis.

Surgery ± Radiotherapy Indicated for: spinal instability, unknown primary requiring biopsy, failure of RT, single bony metastasis, pathological fracture. Improves ambulation outcomes vs RT alone (Patchell trial).

Chemotherapy For chemosensitive haematological malignancies (lymphoma, myeloma, SCLC) as primary or adjunct. Avoid in acute cord compression requiring immediate decompression.

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Nursing Care: Spinal Precautions & Rehabilitation

Spinal Precautions (Until MRI Cleared)

Strict bed rest in neutral spinal alignment
Log-roll technique with minimum 3 nurses for all turns
Firm mattress; consider pressure-relieving overlay
No cervical flexion if cervical spine involved
Document neurological observations hourly (motor strength, sensation, bladder/bowel)

Bladder & Bowel Care

Urethral catheter (neurogenic bladder): strict fluid intake/output
Bowel management protocol: stool softeners, suppositories, digital rectal examination assessment
Skin integrity: 2-hourly repositioning, pressure area care

Other Structural Emergencies

Brain Metastases / Raised ICP

            Headache, morning vomiting, papilloedema, focal neurology. Management: dexamethasone 8mg IV BD, urgent CT head, neurosurgery/oncology referral, whole brain radiotherapy or stereotactic radiosurgery.

Malignant Pericardial Effusion/Tamponade

            Beck's Triad: hypotension + muffled heart sounds + raised JVP. Pulsus paradoxus. ECG: electrical alternans. Management: urgent echocardiogram, pericardiocentesis (emergency), pericardial window.

Malignant Bowel Obstruction

            Colicky pain, distension, absent bowel sounds, vomiting. CT abdomen. Management: NG tube (decompression), octreotide (reduces GI secretions), dexamethasone (oedema), surgical review vs palliative approach.

⚠ Tumour Lysis Syndrome can cause sudden cardiac death from hyperkalaemia. Prevention is more effective than treatment. Identify high-risk patients before commencing cytotoxic therapy and implement prophylaxis.

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Tumour Lysis Syndrome (TLS)

Cairo-Bishop Classification

Massive release of intracellular contents following rapid destruction of tumour cells (spontaneous or treatment-induced). Results in characteristic metabolic derangements.

Cairo-Bishop Laboratory TLS (≥2 of following within 3 days before or 7 days after therapy):

Metabolite	Criterion	Consequence
Uric acid	↑ ≥476 µmol/L or 25% ↑	Urate nephropathy, AKI
Potassium	↑ ≥6.0 mmol/L or 25% ↑	Arrhythmia, cardiac arrest
Phosphate	↑ ≥1.45 mmol/L or 25% ↑	Secondary hypocalcaemia
Calcium	↓ ≤1.75 mmol/L or 25% ↓	Tetany, seizures, arrhythmia

Clinical TLS = Laboratory TLS + one of: Acute kidney injury (creatinine ≥1.5× ULN) · Cardiac arrhythmia/sudden death · Seizure

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Risk Stratification

Risk Level	Cancer Type	Prophylaxis
HIGH	Burkitt's lymphoma, ALL (WBC >100), AML (WBC >100), bulky DLBCL	Rasburicase + IV hyperhydration
INTERMEDIATE	ALL (WBC 10–100), CLL on treatment, other aggressive lymphomas	Allopurinol + IV hydration
LOW	Solid tumours (most), indolent lymphomas, CML (stable)	Oral hydration, monitor

Additional Risk Factors

Bulky disease (tumour burden >10cm)
LDH >2× upper limit of normal (rapid proliferation)
Pre-existing renal impairment (eGFR <60)
Dehydration, oliguria
Pre-treatment elevated uric acid or phosphate

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Prevention & Treatment Protocol

Prevention (Before Chemotherapy)

1
Hyperhydration: IV fluids 3L/m²/day (150–200mL/hr in adults) to maintain urine output >80–100mL/hr. Start 24–48h before chemotherapy.
2
Allopurinol (intermediate risk): 300mg/day orally (or 200–400mg/m²/day). Inhibits xanthine oxidase → reduces uric acid production. Start 24–48h before chemo.
3
Rasburicase (high risk): 0.2mg/kg IV daily for up to 7 days. Recombinant urate oxidase degrades existing uric acid. CONTRAINDICATED in G6PD deficiency (causes haemolysis). Rapid urate reduction (hours vs days).
4
Urinary alkalinisation: Previously used; now NOT routinely recommended (may worsen calcium/phosphate precipitation).

Treatment of Established TLS

1
Hyperkalaemia: Calcium gluconate 10% 10mL IV (cardiac protection), insulin/dextrose, salbutamol nebuliser, sodium bicarbonate, consider dialysis if severe (>6.5 or ECG changes).
2
Hypocalcaemia (symptomatic): Calcium gluconate 10% 10mL IV over 10 min if tetany/seizures. Do NOT treat asymptomatic hypocalcaemia (risks Ca-phosphate precipitation in kidneys).
3
Hyperphosphataemia: Dietary restriction, phosphate binders (sevelamer). Treat underlying TLS.
4
AKI/Oliguria: Continuous renal replacement therapy (CRRT) or haemodialysis if refractory. Early nephrology referral.

Monitoring Frequency (High Risk — Q4–6 hours) U&E · Phosphate · Uric acid · LDH · Calcium · Creatinine · Urine output hourly · Continuous cardiac monitoring · Daily weight

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Hyperviscosity Syndrome

Multiple Myeloma & Waldenström's Macroglobulinaemia

Features (Triad)

Neurological: headache, visual disturbance (dilated retinal veins, papilloedema), confusion, vertigo, hearing loss, stroke-like symptoms
Haemorrhagic: mucosal bleeding, thrombocytopenia, coagulopathy
Cardiovascular: heart failure, circulatory overload

Diagnosis

Serum viscosity measurement (>4 centipoise symptomatic). Fundoscopy (sausage-link retinal veins). Serum protein electrophoresis (paraprotein). IgM level in Waldenström's.

Emergency Treatment

Plasmapheresis (plasma exchange): Rapidly reduces paraprotein level. Rapid symptom relief. Bridge to chemotherapy (bortezomib-based for myeloma; rituximab + chemotherapy for Waldenström's).

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Leukostasis & DIC

Leukostasis (Hyperleukocytosis)

Blast count >100 × 10⁹/L → slugging in microvasculature → CNS infarct/haemorrhage, pulmonary failure

Features: confusion, headache, visual disturbance, respiratory failure, priapism
Emergency: leukapheresis (cytoreduction), hydroxyurea (rapidly lowers blast count), avoid transfusion (increases viscosity), gentle IV hydration

DIC in AML (Acute Myeloid Leukaemia)

Particularly APL (APML/M3): ATRA/arsenic trioxide initiation can precipitate differentiation syndrome + DIC. Management: aggressive coagulation support (FFP, cryoprecipitate, platelets), ATRA continuation (treat underlying cause), haematology emergency.

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GCC Hospital Practice

DHA / DOH / MOH Oncology Nursing Standards

Neutropenic Sepsis: KPI Monitoring

Time-to-antibiotic ≤60 minutes is a mandatory monitored KPI in DHA-licensed oncology centres (Dubai) and DOH-accredited facilities (Abu Dhabi)
Audit cycles track compliance quarterly; results reported to clinical governance
Nurses must document time of fever recognition and time of first antibiotic dose
Rapid triage protocols (oncology-specific) must be available at ED and ward level

SCFHS Oncology Nursing Competencies

Recognition and escalation of oncology emergencies (Saudi Commission)
Chemotherapy certification required for administration
Extravasation management protocols
Patient education in Arabic and English
Participation in tumour board/MDT meetings

GCC-Specific Considerations

High prevalence of hepatocellular carcinoma (HCC) and gastric cancer in GCC population
G6PD deficiency more prevalent in GCC population — screen before rasburicase
High ambient temperatures: dehydration risk in hypercalcaemia/TLS patients
Ramadan considerations: hydration protocols for fasting patients on chemotherapy

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Differential Diagnosis: Key Distinctions

Hypercalcaemia vs SIADH vs TLS

Feature	Hypercalcaemia	SIADH	TLS
Sodium	Normal/↑ (dehydration)	↓ <135	Normal/↑
Calcium	↑ >2.6	Normal/↓ dilutional	↓
Potassium	Normal	Normal/↓	↑ >6.0
Phosphate	Normal/↓ (PTHrP)	Normal	↑
Uric acid	Normal	Normal	↑ >476
Urine output	↑ (polyuria)	↓ (oliguria)	↓ (AKI risk)
Key symptom	Confusion, constipation	Confusion, headache	Arrhythmia, AKI
Fluid treatment	IV NaCl (aggressive)	Fluid restriction	IV hyperhydration

Memory Tip for SIADH vs Hypercalcaemia in Cancer SIADH → Fluid RESTRICT (euvolaemic hyponatraemia) | Hypercalcaemia → Fluid LOAD (IV saline) | TLS → Fluid LOAD + monitor output

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10 MCQ Practice Questions

Hover over each question to reveal the answer and explanation

Q1.A patient on CHOP chemotherapy for lymphoma presents 10 days post-cycle with temperature 38.4°C. ANC is 0.3 × 10⁹/L. What is the maximum acceptable time to antibiotic administration?

30 minutes from blood cultures
60 minutes from presentation
2 hours from triage
4 hours (after microbiology advice)

Answer: B — The UK Sepsis Trust Oncology-adapted Sepsis 6 mandates antibiotics within 60 minutes of recognition of neutropenic sepsis. This is a KPI in GCC oncology centres. Blood cultures should be taken first but must not delay antibiotics beyond 30 minutes.

Q2.A cancer patient has an adjusted calcium of 3.5 mmol/L. Which is the FIRST line treatment?

IV zoledronic acid 4mg over 15 minutes
SC calcitonin 8 IU/kg Q12h
IV 0.9% sodium chloride 4L over 24 hours
SC denosumab 120mg

Answer: C — IV hydration with 0.9% NaCl is always first-line for hypercalcaemia of malignancy. It expands extracellular volume, increases GFR, and promotes calciuresis. Bisphosphonates (zoledronic acid) are definitive but have 48–72h onset. Calcitonin is used as a bridge. Denosumab is for bisphosphonate-refractory cases.

Q3.A patient with known lung cancer presents with facial oedema worse on waking, arm swelling, and headache when bending forward. Which assessment should be performed?

Romberg's sign
Brudzinski's sign
Pemberton's sign
Kernig's sign

Answer: C — Pemberton's sign: raising arms above head produces facial plethora, cyanosis, and respiratory distress due to exacerbation of SVC compression. This is diagnostic for SVCO. The symptoms described (facial oedema worse on waking, headache on bending) are classic for SVCO.

Q4.A myeloma patient receiving rasburicase for TLS prophylaxis develops acute haemolytic anaemia. What is the most likely cause?

Myeloma progression
Zoledronic acid toxicity
Undiagnosed G6PD deficiency
Hyperkalaemia-induced haemolysis

Answer: C — Rasburicase (recombinant urate oxidase) generates hydrogen peroxide as a by-product of urate oxidation. In G6PD-deficient patients, inability to detoxify H₂O₂ causes oxidative haemolysis. G6PD deficiency is more prevalent in GCC populations (Arab and African ancestry). Screen before rasburicase.

Q5.A prostate cancer patient develops sudden onset urinary retention and new bilateral leg weakness. NICE guidelines mandate MRI whole spine within what timeframe if there is acute neurological deficit?

1 hour
4 hours
12 hours
24 hours

Answer: B — NICE CG75 (Metastatic Spinal Cord Compression): MRI whole spine within 24 hours for all suspected MSCC, but within 4 hours if acute neurological deficit is present (weakness, sensory loss, bladder/bowel dysfunction). Urinary retention in a cancer patient = potential cauda equina = 4-hour MRI standard.

Q6.Which electrolyte abnormality in TLS most directly causes cardiac arrest?

Hyperphosphataemia
Hyperuricaemia
Hypocalcaemia
Hyperkalaemia

Answer: D — Hyperkalaemia is the immediate life-threatening electrolyte abnormality in TLS. K⁺ ≥6.5 mmol/L or ECG changes (peaked T waves, widened QRS, sine wave pattern) require emergency treatment: IV calcium gluconate (cardiac membrane stabilisation), insulin/dextrose, salbutamol, and consideration of emergent dialysis.

Q7.For a patient with SVCO, which IV access site is most appropriate?

Right antecubital fossa
Left basilic vein
External jugular vein
Femoral vein

Answer: D — In SVCO, venous return from the upper body is obstructed. IV lines placed in upper limbs or neck contribute to venous congestion and may not deliver drugs to central circulation effectively. All peripheral IV access, blood pressure monitoring, and venepuncture must use lower limb or femoral access until SVCO is resolved.

Q8.Which cancer type is associated with PTHrP-mediated hypercalcaemia and is the most common mechanism overall?

Multiple myeloma (osteolytic)
Colorectal cancer
Squamous cell carcinoma (lung, head & neck)
Lymphoma (vitamin D-mediated)

Answer: C — PTHrP (parathyroid hormone-related protein) secretion accounts for ~80% of hypercalcaemia of malignancy. Squamous cell carcinomas (lung, head & neck, oesophagus, cervix) are the most common PTHrP-secreting tumours. PTHrP mimics PTH: increases osteoclast activity, increases renal calcium reabsorption, and reduces renal phosphate reabsorption.

Q9.A neutropenic patient on Day 8 of AML induction presents with RIF pain, fever, and diarrhoea. CT shows bowel wall thickening of the caecum. What is the diagnosis?

Appendicitis
CMV colitis
C. difficile colitis
Typhlitis (neutropenic enterocolitis)

Answer: D — Typhlitis (neutropenic enterocolitis) classically presents with RIF pain, fever, and diarrhoea in neutropenic patients (most commonly AML induction). CT shows caecal/right colon wall thickening >4mm. Management: bowel rest, broad-spectrum antibiotics including anaerobic cover (add metronidazole), surgical review for complications. Avoid colonoscopy.

Q10.A patient with known myeloma presents with confusion, visual disturbance, and mucosal bleeding. Serum viscosity is elevated. What is the emergency treatment?

Urgent blood transfusion
IV dexamethasone 8mg
IV zoledronic acid
Plasmapheresis (plasma exchange)

Answer: D — Hyperviscosity syndrome (myeloma/Waldenström's) requires emergency plasmapheresis to rapidly reduce paraprotein levels and decrease serum viscosity. Avoid blood transfusion (increases viscosity further). Definitive treatment is bortezomib-based chemotherapy for myeloma. The classic triad is: neurological symptoms + haemorrhage + visual disturbance.

Oncology EmergenciesGCC Nursing Clinical Guide

Absolute Neutrophil Count (ANC) Classification

Typical Onset Post-Chemotherapy

Primary Prophylaxis

Secondary Prophylaxis

Role in Established Neutropenia

High-Risk Patients

Prophylaxis Regimens

Presentation

Diagnosis

Management

Severity Classification

Prevalence

PTHrP-Mediated (Most Common ~80%)

Osteolytic Bone Metastases

Other Mechanisms

Key Causes

Symptoms (remember: FACE)

Pemberton's Sign

SVCO Grading (CTCAE-based)

Immediate Actions

Definitive Treatment Options

Most Common Primary Cancers

Mechanism

Progressive Symptom Sequence

Definitive Treatment Options

Spinal Precautions (Until MRI Cleared)

Bladder & Bowel Care

Other Structural Emergencies

Cairo-Bishop Laboratory TLS (≥2 of following within 3 days before or 7 days after therapy):

Additional Risk Factors

Prevention (Before Chemotherapy)

Treatment of Established TLS

Features (Triad)

Diagnosis

Emergency Treatment

Leukostasis (Hyperleukocytosis)

DIC in AML (Acute Myeloid Leukaemia)

Neutropenic Sepsis: KPI Monitoring

SCFHS Oncology Nursing Competencies

GCC-Specific Considerations

Hypercalcaemia vs SIADH vs TLS

Oncology Emergency Identifier

Oncology Emergencies
GCC Nursing Clinical Guide